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Peripartum Management of Cardiogenic Shock, Pseudoaneurysm and Aortic Valve Endocarditis
Abstract Number: SUN-56
Abstract Type: Case Report/Case Series
INTRODUCTION: Cardiovascular disease and infection are significant contributors to the rising maternal mortality rate in the United States.1 Moderate aortic stenosis (AS) is associated with a relatively low risk in pregnancy; however severe symptomatic AS increases the risk of obstetric and cardiac complications requiring prolonged hospitalization.2
CASE PRESENTATION: A 30-year old G1P0 parturient at 36 4/7 weeks gestation presented in spontaneous labor. Her history was significant for a bioprosthetic aortic valve and ascending aortic graft performed 6 years prior for a stenotic bicuspid aortic valve with ascending aortic aneurysm. TTE one month prior to presentation revealed moderate AS (gradient 34 mmHg, EOA 1.39 cm2) with preserved left ventricular function (EF 66%). Due to refractory non-reassuring fetal status, she underwent urgent cesarean delivery under spinal anesthesia.
Intraoperatively, she remained persistently hypotensive with systolic blood pressures in 80mmHg range despite administration of intravenous fluids, ephedrine, and a phenylephrine infusion. A bedside TTE in the PACU revealed biventricular dysfunction (EF 25-30%), severe AS (gradient 40 mmHg, EOA 0.6 cm2) with new aortic regurgitation (AR) and sinus of Valsalva dilatation; CT angiogram demonstrated aortic root pseudoaneurysm with communication between the non-coronary cusp and posterior LVOT. Consequently emergent aortic valve and root replacement was performed. Intraoperative frank purulence was encountered in the aortic root requiring annular debridement, with intraoperative cultures revealing Streptococcus mitis. Following inability to separate from bypass due to left ventricular dysfunction, VA ECMO was initiated. Five days later she was transitioned to VV ECMO due to severe ARDS for another six days. Extubation was performed on postoperative day 14, and she had no neurologic deficit.
DISCUSSION: This case illustrates undiagnosed subacute bacterial endocarditis resulting in severe AS and aortic root pseudoaneurysm, with clinical symptomatology obscured by intrapartum presentation. Moderate AS without cardiac dysfunction in the parturient is often uncomplicated but requires vigilant surveillance, particularly during the peripartum period. Infective endocarditis (IE) is associated with increased morbidity and mortality for the mother and fetus, with an incidence of approximately 1 in 100,000 pregnancies.3 Complications of IE include cardiac dysfunction, sinus of Valsalva aneurysm, perivalvular extension, and systemic embolization. In this case, immediate postoperative echocardiography, multidisciplinary coordination of care, and operative treatment were integral to patient survival.
REFERENCES: 1) Creanga A, Berg C, Syverson C, et al. Obstet Gynecol 2015;125:5-12, 2) Orwat S, Diller G-P, van Hagen I, et al. J Am Coll Cardiol 2016;68:1727-37, 3) Connolly C, O’Donoghue K, Doran H, et al. Obstet Gynecol 2015;8:102-4.